Friday, October 22, 2010

Octomom and the Physician-Patient Relationship

At a hearing in California to see if his license should be revoked, Dr. Michael Kamrava, the fertility specialist who implanted 12 embryos in Nadya Suleman ("Octomom"), testified that he recommended implanting "only four," but Ms. Suleman was "adamant about using all 12" so he "obeyed her wishes."

Almost 20 years ago, Zeke and Linda Emanuel wrote a now classic article - "Four Models of the Physician-Patient Relationship." Dr. Kamrava's defense exemplifies what the Emanuels called the informative approach to to the physician-patient relationship:

[Under] the informative model, sometimes called the scientific, engineering, or consumer model... the objective of the physician-patient interaction is for the physician to provide the patient with all relevant information, for the patient to select the medical interventions he or she wants, and for the physician to execute the selected interventions. It is the physician's obligation to provide all the available facts, and the patient's values then determine what treatments are to be given. There is no role for the physician's values, the physician's understanding of the patient's values, or his or her judgment of the worth of the patient's values. In the informative model, the physician is a purveyor of technical expertise, providing the patient with the means to exercise control.

I can remember when the values embodied in the "informative model" came into play. It was the late 1960s - 1970s, in the context of the cultural critique of elitism and expertise that manifested itself in medicine as a well-deserved backlash against "paternalism." The profession swung from seeing the patient as a passive obeyer of the "doctor's orders" to seeing the physician as a passive obeyer of the "patient's orders."

The basis for arguing that Dr. Kamrava should lose his medical license is that he so clearly went against the American Society of Reproductive Medicine guidelines on embryo transfer:

For patients under the age of 35 who have a more favorable prognosis, consideration should be given to transferring only a single embryo. All others in this age group should have no more than 2 embryos (cleavage-stage or blastocyst) transferred in the absence of extraordinary circumstances.

But as reckless and ill-advised as his actions were, he was entitled to argue in response that he was following a recognized model of physician-patient interaction, which, in his view, trumped the ASRM guidelines.

If the "Octomom" situation was a single lapse on Dr. Kamrava's part, I would not favor having him lose his license. He would deserve to be publicly chastised and required to practice under the close supervision, paid for at his own expense, of an experienced IVF specialist. (If it was part of a pattern of reckless practice I would support loss of license.)

The paternalistic model and the informative model should both be tossed out the physician-patient window as default orientations. There's often a need for firm guidance - but when it's calibrated to the details of the patient's needs it's not paternalism. Likewise, there's often a need for saying (in effect) to the patient - "now that I understand your values I'll get right to work" - but when that response is calibrated to thoughtful, evidence-based care it's good medical practice, not slavish consumerism.